Multi-modality Treatment of Craniopharyngioma
Emad El Sayed Mohamed Khierallah;
Abstract
Craniopharyngiomas are tumors arising from squamous cell remnants of Rathke's pouch, located in the infundibulum or upper anterior hypophysis ( Fred F. Ferri, 2012)
One of the earliest descriptions of a craniopharyngioma is credited to Zenker, who recognized a suprasellar lesion containing cholesterol crystals in an autopsy study in 1800. Extensive study by Luschka of the squamous epithelial cells in the adenohypophysis followed in 1860. The significance of these findings was not initially recognized, and for many decades they remained overlooked (Karavitaki et al., 2006).
The sellar and supra sellar location of the craniopharynglioma can result in compression or destruction of the optic chiasm, nerves and/or tracts, hypothalamus, pituitary stalk, or adjacent vascular structures. The involvement of these structures directly results in the usual presenting clinical signs, which include progressive visual loss, headaches, and/or endocrine abnormalities. The exact location of the tumor can affect the clinical picture. Retrochiasmatic tumors extend posteriorly and push the chiasm anterorly against the tuberculum sella. These tumor tend to fill the third ventricle and cause hydrocephalus; thus roughly 60% of patients present with headache, 50 % with nausea, 35% with vomiting and 10-20% with lethargy (Anuradha, et al, 2010 ).
Currently useful tools for the neuroradiological characterization of the craniopharyngiomas include computed tomography (CT), magnetic resonance imaging (MRI), and occasionally, cerebral angiography.
Before the introduction of CT scans, air studies and carotid angiography provided the best means for determining the direction and the degree of tumor extension, particularly in large lesions, in which neither changes in the size of the sella nor calcification would indicate their true size (Karavitaki et al., 2006).
The first attempt for surgical removal of craniopharyngioma was credited to Halsteadt who performed transsphenoidal surgery for a patient with symptoms of a sella mass, in 1909 (Karavitaki et al., 2006).
The surgical philosophy regarding the treatment of craniopharyngiomas has vacillated significantly over the last 5 decades. Early operative series demonstrated an extremely high mortality rate of 40%, with only 15% of patients undergoing total removal. By the early 1960s, many felt that aggressive surgery should be abandoned in favor of cytoreduction combined with radiotherapy. In mid-1970s, with improvements in both postoperative endocrinologic care and overall surgical technique, there was renewed support for an aggressive surgical approach. Even today, controversy exists between those who advocate aggressive surgical resection and those who support a more conservative approach (Mehta and Black, 2004).
Complete surgical removal of craniopharyngioma can be achieved with reasonable safety in more than 70% of patients. Recurrence of craniopharyngioma may occur even after apparent radical excision. Prompt management of residual or recurring disease by radiotherapy, repeat surgery, or a combination of both is usually successful in controlling further tumor growth (Anuradha, et al, 2010 )
One of the earliest descriptions of a craniopharyngioma is credited to Zenker, who recognized a suprasellar lesion containing cholesterol crystals in an autopsy study in 1800. Extensive study by Luschka of the squamous epithelial cells in the adenohypophysis followed in 1860. The significance of these findings was not initially recognized, and for many decades they remained overlooked (Karavitaki et al., 2006).
The sellar and supra sellar location of the craniopharynglioma can result in compression or destruction of the optic chiasm, nerves and/or tracts, hypothalamus, pituitary stalk, or adjacent vascular structures. The involvement of these structures directly results in the usual presenting clinical signs, which include progressive visual loss, headaches, and/or endocrine abnormalities. The exact location of the tumor can affect the clinical picture. Retrochiasmatic tumors extend posteriorly and push the chiasm anterorly against the tuberculum sella. These tumor tend to fill the third ventricle and cause hydrocephalus; thus roughly 60% of patients present with headache, 50 % with nausea, 35% with vomiting and 10-20% with lethargy (Anuradha, et al, 2010 ).
Currently useful tools for the neuroradiological characterization of the craniopharyngiomas include computed tomography (CT), magnetic resonance imaging (MRI), and occasionally, cerebral angiography.
Before the introduction of CT scans, air studies and carotid angiography provided the best means for determining the direction and the degree of tumor extension, particularly in large lesions, in which neither changes in the size of the sella nor calcification would indicate their true size (Karavitaki et al., 2006).
The first attempt for surgical removal of craniopharyngioma was credited to Halsteadt who performed transsphenoidal surgery for a patient with symptoms of a sella mass, in 1909 (Karavitaki et al., 2006).
The surgical philosophy regarding the treatment of craniopharyngiomas has vacillated significantly over the last 5 decades. Early operative series demonstrated an extremely high mortality rate of 40%, with only 15% of patients undergoing total removal. By the early 1960s, many felt that aggressive surgery should be abandoned in favor of cytoreduction combined with radiotherapy. In mid-1970s, with improvements in both postoperative endocrinologic care and overall surgical technique, there was renewed support for an aggressive surgical approach. Even today, controversy exists between those who advocate aggressive surgical resection and those who support a more conservative approach (Mehta and Black, 2004).
Complete surgical removal of craniopharyngioma can be achieved with reasonable safety in more than 70% of patients. Recurrence of craniopharyngioma may occur even after apparent radical excision. Prompt management of residual or recurring disease by radiotherapy, repeat surgery, or a combination of both is usually successful in controlling further tumor growth (Anuradha, et al, 2010 )
Other data
| Title | Multi-modality Treatment of Craniopharyngioma | Other Titles | الطرق المختلفه لعلاج الأورام الجمجمية البلعوميه | Authors | Emad El Sayed Mohamed Khierallah | Issue Date | 2014 |
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